CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 3, April 2013
AFRICA
e7
Case Report
Candida parapsilosis
endocarditis on a prosthetic aortic
valve with unclear echocardiographic features
CHARLES MVE MVONDO, FRANCESCA D’AURIA, PASQUALE SORDILLO, ANTONIO PELLEGRINO,
MASSIMO ADREONI, LUIGI CHIARIELLO
Abstract
Fungal endocarditis is rare in comparison with bacterial
endocarditis and is associated with a poor prognosis. Despite
the proven reliability of echocardiography, false negatives
are not uncommon and may influence the therapeutic strat-
egy, as some reports have supported the efficacy of antifun-
gal treatment alone. We report on a case of bioprosthetic
aortic valve
Candida parapsilosis
endocarditis without typical
echocardiograhy findings, which we treated with both anti-
fungal and surgical therapy.
Keywords:
Candida parapsilosis
, prosthetic heart valve, endo-
carditis
Submitted 16/5/12, accepted 24/1/13
Cardiovasc J Afr
2013;
24
: e7–e8
DOI: 10.5830/CVJA-2013-006
Infective endocarditis is a high-risk condition that may affect
native and prosthetic heart valves.
1
Bacterial endocarditis is
more common than fungal endocarditis (FE), with the latter
predominantly caused by
Candida
species.
Candida albicans
represents the main cause of candidaemia, followed by
Candida
parapsilosis
.
FE is correlated with major embolic events and a poor
prognosis.
1
Its incidence has increased over the last two decades
because of an increased use of intravenous drugs, invasive
diagnostic methods and vascular implants, which are major
predisposing factors. Therefore, patients with a prosthetic heart
valve carry a significant risk of contracting FE.
Clinical diagnosis of FE, as for bacterial endocarditis, is
based on the reviewed Duke’s criteria, and echocardiography
2,3
remains a reliable diagnostic tool in the management of FE.
However, even with transoesophageal echocardiography, false
negatives are not uncommon and may influence the therapeutic
strategy, especially when there is no evidence of vegetations or
valve dysfunction.
We describe a case of bioprosthetic aortic valve
C parapsilosis
FE, without typical echocardiography findings. Although
several publications have reported successful FE treatment with
antifungal therapy alone,
4
we performed a combined surgical and
medical approach as recommended by the guidelines.
2
Case report
A 44-year-old female patient with a history of smoking was
admitted to our cardiac surgical unit at the Tor Vergata University
Hospital in Rome. One year earlier she had complained of
dysphonia. Chest computed tomography showed cardiomegaly,
and transthoracic two-dimensional (2D) echocardiography
revealed severe aortic valve stenosis.
Four months later she underwent aortic valve replacement
at our institution, with a bioprosthetic bovine pericardial valve
(Sorin Mitroflow 21 mm), after a short period of medical
treatment for acute pancreatitis and liver impairment in a
medical care unit. Her postoperative course was uneventful
and on the sixth post-operative day, she was transferred to a
rehabilitation clinic. Six weeks later, she had fever (40°C) and
odynophagia, associated with cough and chest pain.
Echocardiography showed an absence of vegetations and
normal function of the native valves and prosthesis. Empirical
intravenous antibiotic treatment with vancomycin (15 mg/kg/
day), gentamicin (1 mg/kg, three times a day) and rifampicin (600
mg/day) was then started. Subsequent blood cultures revealed
the presence of
C parapsilosis
, although both transthoracic and
transoesophageal echocardiography (Fig. 1) had failed to detect
typical lesions.
Department of Cardiac Surgery, Policlinico Tor Vergata, Tor
Vergata University of Rome, Rome, Italy
CHARLES MVE MVONDO, MD,
FRANCESCA D’AURIA, MD
ANTONIO PELLEGRINO, MD
LUIGI CHIARIELLO, MD
Department of Internal Medicine, Infectious Diseases Unit,
Policlinico Tor Vergata, Tor Vergata University of Rome,
Rome, Italy
PASQUALE SORDILLO, MD
MASSIMO ADREONI, MD
Fig. 1. Pre-operative 2D echocardiogram images; (a)
transthoracic echocardiogram: long-axis left parasternal
view; (b) transoesophageal modality: mid-oesophageal
aortic valve short-axis view.
A
B
